CMS/EIP Fiscal Report Center: 10
Services beginning 01/01/2009 ending 03/31/2009 Date of Report:05/18/2009 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 18.00 1350.00 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.00 600.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 15.50 1162.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.00 375.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 24.00 1332.00 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 137 239.00 17925.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 61 108.00 8100.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 54 82.00 6150.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 131 251.00 13930.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 48 75.00 5625.00 75.00
Subtotal (Total Children Is Unduplicated) 196 825.50 56550.00 68.50
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.00 678.92 339.46
OCCT-97530-OT SESSION BY LICENSED OT 62 186.00 12625.68 67.88
OCCT-97530HM-OT SESSION BY OT ASST 5 9.50 516.04 54.32
PHY-97110-PT SESSION BY LICENSED PT 71 209.75 14237.83 67.88
PHY-97110HM-PT SESSION BY PT ASST 2 3.50 190.12 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 97 275.00 18667.00 67.88
Subtotal (Total Children Is Unduplicated) 166 685.75 46915.59 68.42
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Total 1511.25 103465.59 68.46
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Number of Children (Unduplicated) With at Least One Service 342
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Center 10
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
867 1511.25 103465.59 0.00
Other 0 0.00 0.00 0.00
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Total 867 1511.25 103465.59 0.00